Kristen Fischer had been addicted to meth for two years when she got her first taste of heroin at the age of 18.

The majority of people she started hanging out with, she recently recalled, were also using, and "all pretty much had Hep C."

Hepatitis C, a blood-borne virus that attacks the liver and causes inflammation, is so infectious it can spread through a few microscopic dots of blood. Intravenous drug users are among the most high-risk populations for infection because they share syringes, cookers, cotton, water, ties and alcohol swabs, according to the Centers for Disease Control and Prevention.

Fischer, now 28, was aware of the dangers of sharing needles, and she took what she assumed were suitable precautions.

"I thought that if you just bleached the syringes that you were sharing, that would kill everything," Fischer said. "And then I found out later that was not true."

In 2013, Fischer tested positive for hepatitis C — at the same time she learned she was pregnant.

The good news: Fischer has now been clean for almost five years. Following the birth of her daughter, she received what she recalled as "brutal" hepatitis C treatment.

“I thought that if you just bleached the syringes that you were sharing, that would kill everything. And then I found out later that was not true.”

Kristen Fischer

But Fischer's experience is increasingly common, driven by the national opioid epidemic. The national hepatitis C transmission rate among IV-drug users increased by 350 percent from 2011 to 2014, the most recent figures from the U.S. Department of Health and Human Services show.

The state Department of Health Services reports that opioid overdoses killed more than two Arizonans a day last year, with heroin causing almost half of those. Gov. Doug Ducey declared a public-health emergency June 5.

But as the state ramps up efforts to prevent overdoses, blood-borne-disease transmission among intravenous drug users is often overlooked.

"In a lot of these larger conversations, it doesn’t come up, and if it does, it’s kind of an afterthought," Haley Coles, executive director of Sonoran Prevention Works, said.

Sonoran Prevention Works is a mostly volunteer, donation-based organization that provides IV drug users in the West Valley access to clean needles to prevent the spread of disease.

“We don’t condemn people’s drug use and we don’t necessarily condone it, but we’re realistic that it exists,” Coles said. “We work towards any positive change with people, and so if the only positive change a person is capable of making is using a clean syringe that day, then we will wholeheartedly support them.”

"If we don’t very quickly start implementing syringe-access programs throughout the state, we can 100 percent expect to see increased rates of HIV and hepatitis C among people who inject drugs, and their partners and their family members," Coles said.

In 2008, ADHS reported more than 8,900 cases. The year after the funding cut, about 1,700 were reported. In 2015, ADHS reported more than 7,000 cases.

“I would expect that we're certainly missing some cases.”

Jessica Rigler, Arizona Department of Health Services

Coles believes Arizona "absolutely matches" the national trend, if not worse.

"We don't have many syringe-access programs, which means there are fewer opportunities for people to protect themselves." Coles said.

In addition, federal health officials estimate more than half of people infected nationwide don't know they carry the disease.

The National Institute on Drug Abuse estimates that every drug user infected with a blood-borne disease like hepatitis C is likely to infect at least 20 others through shared needles or contact with infected blood. Coles said she believes at least a third of the people who use her organization's services are infected with hepatitis C.

Nonetheless, state health officials are focused on immediate problems caused by the opioid crisis, rather than things that could be problematic down the road.

“We’re certainly looking at the big picture, but ... our focus is just on the opioid epidemic as it is, which is focusing on saving lives,” said Sheila Sjolander, ADHS assistant director of public health prevention services. "We’re really focused on preventing further deaths by expanding access to Naloxone, helping prescribers do best practices with opioid prescriptions and working with our partners to expand access to treatment.”

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A CDC study concluded syringe-access programs are an effective method to reduce hepatitis C transmission rates among injection-drug users and are a cost-effective solution to preventing the spread of disease.

By ADHS's own estimate, drug-related hospital stays for those diagnosed with hepatitis C exceeded $46,000.

By contrast, Coles said it costs her organization just seven cents to purchase a syringe.

Out of the shadows

Since the organization began its weekly syringe-access program in the West Valley in January, it has distributed more than 16,700 syringes and 170 kits of the lifesaving overdose-reversal medication Naloxone. Twenty-four of the latter have been used to successfully reverse overdoses.

The organization doesn't track how many used syringes it has collected, making it impossible to know the number of potentially contaminated needles taken off the streets.

“What the evidence has shown over and over again is that people will use syringes whether or not you give them a clean one.”

"The most common response we hear is that we’re encouraging people to use drugs — if we’re giving people syringes, that’s like giving them a free pass to use,” Coles said.

But Coles argues it is fallacious thinking. “What the evidence has shown over and over again is that people will use syringes whether or not you give them a clean one."

Sean Driskill, a former heroin user who now volunteers for Sonoran Prevention Works, said clean needles are a humane way to help addicts protect themselves.

“People are going to shoot up drugs anyways, so we might as well ensure that they do it safely so they can stay healthy, so maybe the small percentage of people who survive and try to get treatment have a fighting chance,” Driskill said. “Every one of these people, at the end of the day, underneath all of these circumstances, are people just like us.”

Driskill was one of the lucky ones. The first time he shot up was with a dirty needle, and he continued to do it. But he never contracted hepatitis C.

“I didn’t really understand the severity of it," Driskill said.

Providing access to clean needles, Coles said, is the most practical way to stop the spread of disease. It also establishes a point of contact with users to share safety information.

“What we’ve found from people who are referred to drug treatment from syringe-access programs is that they are five times more likely to go to those treatment programs,” Coles said. “They’ve proven to be a really successful way to make referrals and build relationships with people who are actively using drugs who aren’t connected to any other service.”

Of the nearly 600 interactions her organization has had with users this year, Coles estimates Sonoran Prevention Works has made more than 100 referrals to outside services like drug counseling or rehabilitation centers.

A legal gray area

Susan Jernstedt, a Sonoran Prevention Works volunteer, prepares outreach kits in Phoenix for distribution in a parking lot in the West Valley.(Photo: Mark Henle/The Republic)

Under Arizona law, anyone can walk into a pharmacy and buy a package of syringes from behind the counter without a prescription, theoretically giving intravenous drug users regular access to clean syringes. In reality, it's not as simple.

For example, CVS Pharmacy sells syringes, but they "cannot be sold with the knowledge it will be used to inject controlled substances," CVS spokeswoman Erin Britt said.

A technician at a CVS in south Phoenix said pharmacists won't sell them unless the purchaser has a prescription on file for medication such as insulin or testosterone that requires a needle for administration. A pack of 10 syringes costs around $3.

Walgreens spokesman Phil Caruso said its pharmacies do not require a prescription to purchase syringes. Corporate policy "allows pharmacists to use professional judgment when dispensing" syringes, but the purchaser must be 18 years or older.

Even if a syringe is obtained at a pharmacy, possessing it for drug use is a Class 6 felony under state paraphernalia laws, calling for a minimum sentence of six months in prison for first-time offenders.

Coles said the criminalization of syringes forces users to share needles. An associated risk: If public-health workers or law enforcement officials are stuck by a needle passed among users, chances are good they will be exposed to infection.

A volunteer who started a syringe-access program in Globe nearly a year ago has had two accidental needle sticks. The worker, who asked not to be named for fear of a backlash against the program, said accidental needle sticks are common.

Police officers often are at risk during searches or pat-downs if a user has hidden a syringe. The Phoenix Police Department reported 28 accidental needle sticks from July 1, 2016, through June 30, 2017.

Coles said while her organization would not be able to operate without the support of local law enforcement, the laws themselves force her organization to provide a potentially life-saving public-health service "in this almost criminal way."

"We’re trying to encourage people to take better care of themselves, but then we come have them access these services behind a fast-food restaurant in a parking lot out of a car," Coles said. "And by our actions, we’re reinforcing the criminalization of their actions, rather than the fact that they have a public-health issue.”